Individual
KEANDREA BACON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
120 WHIRLAWAY DR, ELLENWOOD, GA 30294-3259
(404) 444-3887
Mailing address
120 WHIRLAWAY DR, ELLENWOOD, GA 30294-3259
(404) 444-3887
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
RN233963
GA
367500000X
Certified Registered Nurse Anesthetist
Primary
CRNA233963
GA
Other
Enumeration date
07/01/2024
Last updated
09/23/2025
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